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  • Peter Lombard MD

Guam COVID update for April 25th

Updated: May 1

2 cases yesterday reported yesterday, and to the detriment of public enlightenment, no information was provided about where these cases came from, if they were related to other cases, how serious they are, or if there appear to be new clusters related to these cases.


Is this an early bad signal? After a string of days when we had 0 or 1 cases, if we start to see 2+ new cases per day for a few days in a row, it certainly bears close watching, but may not necessarily signal a harbinger of a surge. As we are now testing more through multiple modalities, it’s not unexpected we are catching new cases. As long as they can clearly be traced to positive contacts even with microclusters within families, this should not lead to an overwhelming wave of new cases. Even 15 new cases in a week is a level that our public health tracers and medical system should be able to handle.


COVID-19 origins. Massive congratulations to Guam’s own Lenore Pipes. She co-authored this preprint paper that seeks to understand where this coronavirus strain originated. It’s very technical. My take home points (which I vetted with Lenor): Covid-19 was NOT a lab concoction, it was unlikely a recombination event with pangolin strain unless high “hypermutability”; and much more likely a recombination event with a bat strain.

https://www.biorxiv.org/content/10.1101/2020.04.20.052019v1?


Apples to apples. I’ve performed a cursory analysis (Guam-centric) comparing island nations. See attachments and slides. I selected about 21 island nations and added them to charts that show the total deaths per capita, and the number of new cases per capita (3-day rolling). There are caveats for areas with smaller populations and fewer cases and deaths, this increases the noise. But some trends can be seen. The largest islands have populations in the 3 million range, the smaller ones 50 thousand or less. I also included for comparison the US, Italy, Taiwan, and South Korea.


First off on both charts you’ll notice Bermuda is an outlier, and I’d like to spend time looking at what they’re doing wrong. Maybe they took longer to close their airport, shut down businesses, and the like. Generally though you see almost all island nations are orders of magnitude better off than other western countries on both charts.


For daily new cases (link), most island nations are reporting less than 10 daily cases per million (or 1 case per 100,000, meaning Guam would be at about 1.7 cases per day). Guam is at the top end of that grouping, perhaps indicating we should be performing better. As there are some much more populous nations here (New Caledonia, Trinidad and Tobago, Jamaica, French Polynesia), I think we should aspire to perform to their levels. The US is worse off compared to Italy who have reached their peak and are seeing fewer daily new cases than a week or two ago.


On the deaths per capita chart (link) you’ll see most island nations are seeing 30 deaths per million or less. Again Guam is closer to the top of this range. Remember it’s likely we are underreporting the # of COVID deaths (along with everyone else), but even if you double Guam’s death rate per capita, we are still outperforming the US by a factor of 5! And again many more populous island nations have lower death rates than Guam. So even if the island nations are underreporting deaths, they still in general are still faring much better than most other countries.


To see Taiwan, Japan, and South Korea outperforming much smaller island nations on both charts, is a testament to the robustness of their pandemic measures.


Conclusions? Evidence suggests island nations generally are outperforming larger, more populous countries by a wide margin, with rare exceptions. If we really want to know how much better or worse could be doing, it might be more appropriate to compare to more similar islands, such as the Bahamas, Barbados, St Lucia, St Vincent and the Grenadines, French Polynesia, and New Caledonia.


#falsedichotomy

We’re getting more and more polar voices to “end the lockdown!” or to “keep the lockdown!”. These choices present a false dichotomy, like the parachute analogy that has been going around on social media. It’s not all or nothing. There are so many nuances to how you could thoughtfully find a middle ground. We may disagree on where that middle ground lies, but let’s agree to not be polarized on one side or the other?


It’s clear from Singapore and to some extent pockets in Japan that it’s dangerous to relax measures too much. Sweden however is a different beast. They are actively trying to increase herd immunity while protecting their vulnerable. Despite the increase in deaths that naysayers are (appropriately) pointing out, they may be heading in the right direction overall. Their cases per capita are average compared to the rest of the world, and while their death rate per capita is higher than the US, it’s far lower than Spain and Italy. All the while their seroprevalence is increasing. It may be up to 30% of the population according to a recent article. If this is true, it’s far better than the 5% or less that is likely for much of the rest of the world at this point in time.


The catch-22 here is that while we don’t want to see new cases in the community, if those new cases come trickling in slowly, and these cases are in healthy people that won’t be hospitalized or die, they are actually helping us increase our prevalence in a safe controlled manner. I’m not advocating that just yet as I don’t think we have the social awareness to pull this off. But it will be interesting to see what happens in Sweden.

https://uncoverdc.com/2020/04/23/sweden-shatters-lock-down-model-as-curves-stay-flat/?


Perhaps up to 6% of positive cases can be re-infected or relapse. Dr. Kim shared with me an insightful interview with Professor Woo-Joo Kim from Korea University Guro Hospital.

https://www.youtube.com/watch?v=QwoNP9QWr4Y&feature=youtu.be&fbclid=IwAR3qzSdNe28QY1KMgdKWBi2xdPtvwkVBTYEewaqUNRah3_YXYJ9MqG6JC5g


I keep coming back to the superspreader event (SSE) article. Seemingly inconsequential things like staggering people in a line, offsetting yourself from the person you’re talking to, placing restaurant chairs and tables diagonally or at off angles might make a difference. And of course, #masksforall.

https://quillette.com/2020/04/23/covid-19-superspreader-events-in-28-countries-critical-patterns-and-lessons/


Cat scan findings even in mild disease. These could be useful in the diagnostic toolbox. A few lesions on CT hopefully have no long term clinical significance.

https://pubs.rsna.org/doi/10.1148/ryct.2020200110




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